What's really behind the Saskatchewan RN dispute with LPNs

For going on two years, the Saskatchewan Union of Nurses (SUN) has waged a heated campaign against changes to the scope of practice of licensed practical nurses (LPNs). Recently, SUN members demanded a special meeting of the Saskatchewan Registered Nurses Association (SRNA), the profession's regulatory body, at which they proposed the ouster of the executive director and the members of the governing council for being insufficiently hostile to the changes to the LPN bylaws.What's behind the conflict, and what are the lessons for health care and health policyLPNs, like RNs, are a self-regulating profession. Like all self-regulating professions, their authority derives entirely from government. Their regulatory role is not to advocate for the profession; that is the job of unions and professional associations. It is solely to protect and advance the public interest. In some cases, mainly where numbers are relatively small, one body combines the regulatory and professional association roles. (SALPN is one of them.) This carries the risk of blurring the public interest and professional advocacy, and the general trend is toward separation. Where they remain joined, the regulatory role must take precedence.In 2014, SALPN, after consultation with employers, the SRNA and the government, proposed new bylaws that expanded the scope of practice of LPNs in three areas: orthopedics, hemodialysis and perioperative care. Only LPNs who take advanced training and work in the appropriate care teams can take on the expanded roles.Moreover, the bylaw changes merely reflect changes that had already occurred — that is, LPNs were already in these roles in many settings. The SRNA's own legal opinion stated, "Today, everyone acknowledges that there are overlapping scopes of practice between LPNs and RNs. It is further acknowledged that scopes of practice evolve over time largely due to changes in the educational programs. Today, LPNs are doing work that ten years ago would have been clearly RN work, just as RNs are doing work that ten years ago was clearly only done by medical doctors."It appears that everyone acknowledges these realities except SUN. It has been on the warpath ever since, claiming that LPNs are incapable of safely working in the designated areas and imploring the SRNA to fight back. This lays bare the regulator's dilemma. It is obligated to support evidence-based measures that serve the public, yet its council is elected by RNs, the great majority of whom are SUN members, who in this case oppose the measures. The system is based on the optimistic assumption that RNs fully understand and accept that they elect council members to do the public's bidding, not their own.So whom are we to believe SUN has produced no evidence that LPNs cannot competently do the work. Employers, accountable for any adverse events attributable to an improper division of labour, have had no issue with the expanded LPN scope. The government has an obvious interest in the quality and safety of the system. It, too, is comfortable with the expansion. SALPN has nothing to gain from its members wading into practice terrain for which they are unfit. Doing so would damage the profession's credibility and put their own members at legal and psychological risk.Hence the logical conclusion is that this is a war over turf and jobs. RNs are keen to advocate for bigger roles in primary care and chafe when physicians resist. Yet what they wish for themselves — the ability to deploy all of their knowledge, skills, and experiences to help patients and expand their career horizons — SUN wishes to deny to LPNs. That they couch their territorial ambitions in public safety language is simply camouflage for the real agenda.The LPNs and the new bylaws will survive and this, too, shall pass. Nonetheless it should serve as a cautionary tale, the lessons from which are ignored at our peril.Whatever SUN has gained in terms of solidarity and advocacy among its members may be more than offset by the potential damage inflicted on the notion of professional self-regulation. If SUN either now or in the future is successful in inciting its members to elect a parochial and self-serving SRNA council that forsakes its public interest mandate, it will raise doubts about the sustainability of the self-regulation model. Regulators derive their legitimacy precisely by doing what has drawn the ire of SUN: they overrule narrower professional interests in service of ours. SUN can and should fight battles based on solid evidence and sound reasoning. It's never a good scope